Topical steroid

Topical steroids are the topical forms of corticosteroids. Topical steroids are the most commonly prescribed topical medications for the treatment of rash, eczema, and dermatitis. Topical steroids have antiinflammatory properties, and are classified based on their vasoconstriction abilities. There are numerous topical steroid products, and the number increases daily. All the preparations in each class have the same antiinflamatory properties, but essentially differ in base, and price.

History

Corticosteroids were first made available for general use around 1950.

How to choose a steroid

The best result is obtained when the correct strength is matched with a specific diagnosis and anatomic location. Essentially, weaker topical steroids are utilized for thin-skinned and sensitive areas, especially areas under occlusion (armpit, groin, buttock crease, breast folds). Weaker steroids are used on the face, eyelids, diaper area, perianal skin, and intertrigo of the groin or body folds. Moderate steroids are used for atopic dermatitis, nummular eczema, asteatotic dermatitis, lichen sclerosis et atrophicus of the vulva, scabies (after scabiecide), severe dermatitis. Strong steroids are used for psoriasis, lichen planus, discoid lupus, chapped feet, lichen simplex chronicus, severe poison ivy, alopecia areata, nummular eczema, and severe atopic dermatitis in adults.

How to use a topical steroid

To prevent tachyphylaxis, a topical steroid is often prescribed to be used on a week on, week off routine. Some recommend using the topical steroid for 3 consecutive days on, followed by 4 consecutive days off.

Weak topical steroid are reserved for the eyelids, facial skin, body folds, arm pits, groins, genitals, and perianal region.

Moderate topical steroids are used in wider unoccluded parts of the body like the trunk, arms, and legs.

Strong topical steroids are used in limited skin areas to minimize systemic side effects. They are indicated for thick-skinned areas like the palms, soles of feet, and certain dermatitis such as lichen planus and psoriasis of the limbs.

Long-term use of topical steroids can lead to secondary infection with fungus or bacteria (see tinea incognito), skin atrophy, telangiectasia (prominent blood vessels), skin bruising and fragility.

Side effects of topical steroids

• Diabetes Mellitus
• Osteoporosis
• Allergic contact dermatitits (see steroid allergy)
• Skin atrophy
• Addiction or rebound syndrome: Abrupt withdrawal of these medications can lead to aggressive recurrence of the condition.
• Perioral dermatitis: This is a rash that occurs around the mouth and the eye region that has been associated with topical steroids.
• Ocular effects: Topical steroid drops are frequently used after eye surgery but can also raise intra-ocular pressure (IOP).
• Tachyphylaxis: The acute development of tolerance to the action of a drug after repeated doses. Significant tachyphylaxis can occur by day 4 of therapy. Recovery usually occur after 3 to 4 days rest. This has led to therapies such as 3 days on, 4 days off; or one week on therapy, and one week off therapy.
• Vehicle-related adverse effects
• Other local adverse effects: These include facial hypertrichosis, folliculitis, miliaria, genital ulceration, and granuloma gluteale infantum. Long term use has resulted in Norwegian scabies, Kaposi's sarcoma, and other unusual dermatosis.

Soft steroids

Soft steroids are topical steroids with a low rate of side effects in relation to their anti-inflammatory potency. These include hydrocortisone aceponate, hydrocortisone buteprate, methylprednisolone aceponate, mometasone furoate and prednicarbate.

Classification systems

See also: ATC code D07

USA system

The USA system utilizes 7 classes. Class I is the strongest, or superpotent. Class VII is the weakest and mildest.

Group I

Very potent: up to 600 times stronger than hydrocortisone.

• Clobetasol propionate 0.05% (Dermovate)
• Betamethasone diproprionate 0.25% (Diprolene)
• Halbetasol proprionate 0.05% (Ultravate)
• Diflorasone diacetate 0.05% (Psorcon)

Group II

• Fluocinonide 0.05% (Lidex)
• Halcinonide 0.05% (Halog)
• Amcinonide 0.05% (Cyclocort)
• Desoximetasone 0.25% (Topicort)

Group III

• Triamcinolone acetonide 0.5% (Kenalog, Aristocort cream)
• Mometasone furoate 0.1% (Elocon ointment)
• Fluticasone proprionate 0.005% (Cutivate)
• Betamethasone diproprionate 0.05% (Diprosone)

Group IV

• Fluocinolone acetonide 0.01-0.2% (Synalar, Synemol, Fluonid)
• Hydrocortisone valerate 0.2% (Westcort)
• Hydrocortisone butyrate 0.1% (Locoid)
• Flurandrenolide 0.05% (Cordran)
• Triamcinolone acetonide 0.1% (Kenalog, Aristocort A ointment)
• Mometasone furoate 0.1% (Elocon cream, lotion)

Group V

• Triamcinolone acetonide 0.1% (Kenalog, Aristocort cream, lotion)
• Fluticasone propionate 0.05% (Cutivate cream)
• Desonide 0.05% (Tridesilon, DesOwen ointment)
• Fluocinolone acetonide 0.025% (Synalar, Synemol cream)
• Hydrocortisone valerate 0.2% (Westcort cream)

Group VI

• Prednicarbate 0.05% (Aclovate cream, ointment)
• Triamcinolone acetonide 0.025% (Aristocort A cream, Kenalog lotion)
• Fluocinolone acetonide 0.01% (Capex shampoo, Dermasmooth)
• Desonide 0.05% (DesOwen cream, lotion)

Group VII

The weakest class of topical steroids. Has poor lipid permeability, and can not penetrate mucous membranes well.

• Hydrocortisone 2.5% (Hytone cream, lotion, ointment)
• Hydrocortisone 1% (Many over-the-counter brands)

New Zealand method

Some countries utilize only 4 classes.

Class 1

Very potent (up to 600 times as potent as hydrocortisone) Clobetasol propionate (Dermovate Cream/Ointment) Betamethasone dipropionate (Diprosone OV Cream/Ointment)

Class 2

Potent (50-100 times as potent as hydrocortisone)

• Betamethasone valerate (Beta Cream/Ointment/Scalp Application, Betnovate Lotion/C Cream/C Ointment, Daivobet 50/500 Ointment, Fucicort)
• Betamethasone dipropionate (Diprosone Cream/Ointment)
• Diflucortolone valerate (Nerisone C/Cream/Fatty Ointment/Ointment)
• Hydrocortisone 17-butyrate (Locoid C/Cream/Crelo Topical Emulsion/Lipocream/Ointment/Scalp Lotion)
• Mometasone furoate (Elocon Cream/Lotion/Ointment)
• Methylprednisolone aceponate (Advantan Cream/Ointment)

Class 3

Moderate (2-25 times as potent as hydrocortisone)

• Clobetasone butyrate (Eumovate Cream)
• Triamcinolone acetonide (Aristocort Cream/Ointment, Viaderm KC Cream/Ointment, Kenacomb Ointment)

Class 4

Mild

• Hydrocortisone 0.5-2.5% (DermAid Cream/Soft Cream, DP Lotion-HC 1%, Skincalm, Lemnis Fatty Cream HC, Pimafucort Cream/Ointment)

Japan classification

Japan rates topical steroids from 1 to 5, with 1 being strongest.

The four groups of steroids

The highlighted steroids are often used in the screening of allergies to topical steroid and systemic steroids. When one is allergic to one group, one is allergic to all steroids in that group.

Group A

Hydrocortisone, Hydrocortisone acetate, Cortisone acetate, Tixocortol pivalate, Prednisolone, Methyprednisolone, and Prednisone.

Group B

Triamcinolone acetonide, Triamcinolone alcohol, Amcinonide, Budesonide, Desonide, Fluocinonide, Fluocinolone acetonide, and Halcinonide.

Group C

Betamethasone, Betamethasone sodium phosphate, Dexamethasone, Dexamethasone sodium phosphate, and Fluocortolone.

Group D

Hydrocortisone-17-butyrate, Hydrocortisone-17-valerate, Aclometasone dipropionate, Betamethasone valerate, Betamethasone dipropionate, Prednicarbate, Clobetasone-17-butyrate, Clobetasol-17-propionate, Fluocortolone caproate, Fluocortolone pivalate, and Fluprednidene acetate.

See also

• Topical Harry AGT